Tuesday, 20 October 2020
webAIRS Information Threads

A prospective six-month audit of airway incidents during anaesthesia in twelve tertiary level hospitals across Australia and New Zealand

This audit of airway incidents was conducted over six months in 12 tertiary level hospitals across Australia and New Zealand. During that time, 131,233 patients had airway management and 111 reports were submitted (incidence 0.08%). The airway incidents included a combination of difficult airway management (83), oxygen desaturation (58), aspiration (19), regurgitation (14), laryngospasm (16), airway bleeding (10), bronchospasm (5) and dental injury (4), which gave a total of 209 events in 111 reports. Most incidents occurred during general anaesthesia (GA; 83.8%) and normal working hours (81.1%). Forty-three percent were associated with head and neck surgery and 12.6% with upper abdominal procedures. Of these patients, 52% required further medical treatment or additional procedures and 16.2% required unplanned admission to an intensive care unit or a high dependency unit. A total of 31.5% of patients suffered from temporary harm and 1.8% from permanent harm. There was one death. The factors associated with a high relative risk (RR) of an airway incident included American Society of Anesthesiologists Physical Status (ASA PS) (ASA PS 2 versus 1, RR 1.75; ASA PS 3 versus 1, RR 3.56; ASA PS 4 versus 1, RR 6.1), and emergency surgery (RR 2.16 compared with elective). Sedation and monitored anaesthesia care were associated with lower RRs (RR 0.49 and RR 0.73 versus GA, respectively). Inadequate airway assessment, poor judgement and poor planning appeared to be contributors to these events. Future teaching and research should focus on these areas to further improve airway management and patient safety.

Yasmin Endlich, Linda Beckmann, Siu-Wai Choi and Martin Culwick

A Case Report From the Anesthesia Incident Reporting System. - ASA Monitor

Summary: HFNO is a valuable addition to the techniques available for managing the oxygenation of patients in various anesthetic situations. Given its potential to deliver large quantities of oxygen per unit time to a source of ignition, there is particular need for vigilance in respect to potential fires whenever HFNO is used. The risk of fire must be kept firmly in mind whenever surgery is performed around the head and neck, whether supplementary oxygen is used or not.

Dr M.Culwick and Prof.Alan Merry

Unanticipated difficult airway events - Australasian Anaesthesia (The Blue Book)

Unexpected difficult airways are always challenging. This article captures the information regarding difficult airway in an easy to understand Bowtie Diagram.................. Published in Australasian Anaesthesia 2019.

Yasmin Endlich and Martin Culwick

Aspiration during anaesthesia in the first 4000 incidents reported to webAIRS

The first 4000 reports to the webAIRS anaesthesia incident reporting database were used to evaluate pulmonary aspiration in patients undergoing procedures under general anaesthesia or sedation. Demographic data, predisposing factors, outcome and potential preventative measures were evaluated. In these reports, 121 cases of aspiration were identified. Aspirated substances included gastric contents, bile type fluids, blood and solids; 60 (49.6%) patients were admitted to the intensive care unit/high dependency unit, and 43 (35.5%) required mechanical ventilation. Aspiration was associated with significant harm in >50% of reports, and eight (6.6%) patients died.

Michal T Kluger, Martin D Culwick, Matthew M Moore and Alan F Merry

Operating theatre fires – adding more oxygen to the mix.

WebAIRS has received a number of cases where oxygen pooled under the drapes during head and neck procedures has lead to a fire. Two of these involved high flow nasal oxygen (HFNO). This article describes the two cases invloving HFNO. In summary, it is advisable that anaesthetists use the lowest FiO2 possible to support the patient’s oxygen saturation at a safe level. Close communication between surgeons, anaesthetists and nursing staff throughout these procedures is recommended. Oxygen pooling under the drapes should be avoided by providing good airflow around the sterile area. The possible use of suction to scavenge high oxygen pockets trapped under drapes and in contact with the patient should also be considered.

K.B. Greenland M. Stokan and M. Culwick

Rising to the occasion - Institutional standardization and organization of equipment for 'can't intubate, can't oxygenate' (CICO) crisis

Summary: ‘Can’t intubate, can’t oxygenate’ (CICO) scenario is a rare anesthesia crisis for which the management has been suboptimal in the past. Inadequacy and disorganization of airway equipment have been identified as one of the latent factors that contribute to the failure of CICO management. We initiated a quality improvement project to review the equipment aspect of CICO management in our department. We revised our emergency front of neck access (FONA) airway equipment based on available evidence and organized the equipment with custom-made CICO kits. The CICO kits could potentially streamline management, and institutionally standardized equipment across all critical care departments. Our approach may serve as a practical guide for implementation of standard practice for CICO management.

Foong, W.M., Wyssusek, K.H., Culwick, M.D. and van Zundert, A.A.J.

What are we injecting with our drugs?

Summary: In preparation for a case, an anaesthetist opened a 20 ml glass vial of propofol and aspirated the propofol into a syringe via a blunt drawing-up needle. Increased resistance was felt with aspiration. On inspection, a shard of glass was found at the tip of the drawing-up needle. The shard was presumed to be from the propofol ampoule, and to have fallen into the solution upon snapping open its glass tip. This illustrative case raises the issue of contamination of drugs by particles introduced during the drawing-up process. It also highlights the possibility that during the drawing-up process, intravenous drugs may become contaminated not just with particles, but with microorganisms on the surface of the particles. In this article, we discuss relevant recent research of the implications of this type of drug contamination. We draw attention to the need for meticulous care in drawing up and administering intravenous drugs during anaesthesia, particularly propofol.

AF Merry, DA Gargiulo, LE Fry

Awareness during general anaesthesia in the first 4,000 incidents reported to webAIRS

The aim of this study was to analyse the incidents related to awareness during general anaesthesia in the first 4,000 cases reported to webAIRS—an anaesthetic incident reporting system established in Australia and New Zealand in 2009. Included incidents were those in which the reporter selected “neurological” as the main category and “awareness/dreaming/nightmares” as a subcategory, those where the narrative report included the word “awareness” and those identified by the authors as possibly relevant to awareness. Sixty-one awareness-related incidents were analysed: 16 were classified as “awareness”, 31 were classified as “no awareness but increased risk of awareness” and 14 were classified as “no awareness and no increased risk of awareness”. Among 47 incidents in the former two categories, 42 (89%) were associated with low anaesthetic delivery and 24 (51%) were associated with signs of intraoperative wakefulness. Memory of intraoperative events caused significant ongoing distress for five of the 16 awareness patients. Patients continue to be put at risk of awareness by a range of well-described errors (such as syringe swaps) but also by some new errors related to recently introduced anaesthetic equipment, such as electronic anaesthesia workstations.

K Leslie, MD Culwick, H Reynolds, JA Hannam, AF Merry

Incident reporting, aviation and anaesthesia

Too many patients are harmed by healthcare intended to help them. Anaesthesia, an essential component of healthcare, is thought to have become very safe in recent years—at least in high income countries. Indeed, anaesthetists are often held up as leaders in the pursuit of patient safety. It is easy to forget that this was not always the case: a seminal paper by Macintosh, drawing attention to basic failures in anaesthetic practice that were then contributing to avoidable deaths, is worth reading. Macintosh’s paper is surprisingly forthright and honest, and was an early example of the importance of learning from mistakes in healthcare. We have certainly made progress since then, but there is no room for complacency. The NAP43 and NAP54 publications are timely reminders that serious complications do still occur in anaesthesia today, and that they often involve relatively healthy individuals undergoing apparently straightforward surgical procedures under the care of well-trained anaesthetists. We (as anaesthetists) may be generic leaders in patient safety, but there is still much for us to learn about safety in our own speciality. The need to continue learning and improving is the primary reason for reporting and reviewing incidents. To read more click on the link below.

AF Merry, B Henderson

Article in the Medical Observer

The article in the Medial Observer is based upon the recent article published in Anaesthesia and Intensive Care relating to risk and harm reported in the first 4000 incidents analysed by ANZTADC. It was evident that the Medical Observer article had sensationalised the findings. DR Neville Gibbs (ANZTADC Chair) responded to assure the readers that anaesthesia is safe when the number of anaesthetics per year is taken into account, and that the aim of the study is to improve patient safety during anaesthesia. The following points were made in the response.

  • The aim of anaesthetists is to avoid all incidents. That is why studies of this type are undertaken.
  • Patients should be reassured that there are well over 2.5 million anaesthetics each year in Australia and New Zealand, or over 50,000 each week, so the chance of a patient having any incident at all is extremely small.
  • The majority of incidents result in no harm.
  • Further analysis of the 4000 incidents in the webAIRS database will investigate the relationship between harm and preventability, and ways to further improve patient safety.
  • This type of activity is an example of many many safety measures and initiatives that support an extremely high level of anaesthetic safety in Australia and New Zealand.

If you have any further points that you would like to contribute please contact anztadc@anzca.edu.au
There is a link to the article below.

M Culwick

Risk of harm or death in the first 4,000 incidents reported to webAIRS

Patient and procedural factors associated with an increased risk of harm or death in the first 4,000 incidents reported to webAIRS. Anaesthesia and Intensive Care, Volume 45, Issue 2, Pages
This report describes an analysis of patient and procedural factors associated with a higher proportion of harm or death versus no harm in the first 4,000 incidents reported to webAIRS. The report is supplementary to a previous cross-sectional report on the first 4,000 incidents reported to webAIRS.

NM Gibbs, MD Culwick, AF Merry

The first 4000 incidents reported to webAIRS (overview)

A cross-sectional overview of the first 4,000 incidents reported to webAIRS, a de-identified web-based anaesthesia incident reporting system in Australia and New Zealand. Published in January 2017.

NM Gibbs, MD Culwick, AF Merry

Chewing gum in the preoperative fasting period: an analysis of de-identified incidents reported to webAIRS

Summary The role of preoperative fasting is well established in current anaesthetic practice with different guidelines for clear fluids and food. However, chewing gum may not be categorised as either food or drink by some patients, and may not always be specified in instructions given to patients about preoperative fasting. The aim of this paper was to review anaesthesia incidents involving gum chewing reported to webAIRS to obtain information on the risks, if any, of gum chewing during the preoperative fasting period. There were nine incidents involving chewing gum reported between late 2009 and early 2015. There were no adverse outcomes from the nine incidents other than postponement of surgery in three cases and cancellation in one. In particular, there were no reports of aspiration or airway obstruction. Nevertheless, there were five cases in which the gum was not detected preoperatively and was found in the patient’s mouth either intraoperatively or postoperatively. These cases of undetected gum occurred despite patient and staff compliance with their current preoperative checklists. While the risk of increased gastric secretions related to chewing gum preoperatively are not known, the potential for airway obstruction if the gum is not detected and removed preoperatively is very real. We recommend that patients should be specifically advised to avoid gum chewing once fasting from clear fluids is commenced, and that a specific question regarding the presence of chewing gum should be added to all preoperative checklists.

NM Gibbs, S Shanmugam, G Goulding, K Taraporewalla, MD Culwick

Bow-tie diagrams for risk management in anaesthesia

Bow-tie analysis is a risk analysis and management tool that has been readily adopted into routine practice in many high reliability industries such as engineering, aviation and emergency services. However, it has received little exposure so far in healthcare. Nevertheless, its simplicity, versatility, and pictorial display may have benefits for the analysis of a range of healthcare risks, including complex and multiple risks and their interactions. Bow-tie diagrams are a combination of a fault tree and an event tree, which when combined take the shape of a bow tie. Central to bow-tie methodology is the concept of an undesired or ‘Top Event’, which occurs if a hazard progresses past all prevention controls. Top Events may also occasionally occur idiosyncratically. Irrespective of the cause of a Top Event, mitigation and recovery controls may influence the outcome. Hence the relationship of hazard to outcome can be viewed in one diagram along with possible causal sequences or accident trajectories. Potential uses for bow-tie diagrams in anaesthesia risk management include improved understanding of anaesthesia hazards and risks, pre-emptive identification of absent or inadequate hazard controls, investigation of clinical incidents, teaching anaesthesia risk management, and demonstrating risk management strategies to third parties when required.

MD Culwick, AF Merry, DM Clarke, K Taraporewalla, NM Gibbs

Incident Reporting at the Local and National Level

Brief History We cannot fix what we do not know. From the very first anesthetic, there have been reported cases of harm.1 Early on, these reports were often anecdotal, passed by word-ofmouth or letter among a small group of colleagues. Over time, anesthesiologists began to focus on the most devastating “incidents” associated with anesthesia and unexplained deaths. One of the first large studies on anesthesia mortality reviewed 599,548 patients who had received anesthesia2 and noted an overall mortality related partly or wholly to anesthesia of 1 in 3000 cases. The authors noted that there was an increase in anesthesia death rate when muscle relaxants were used, but accepted that there was no evidence that this was directly related to the drugs. The mechanism of these deaths was frequently cardiovascular collapse and the authors implied that this might have been because of the ganglion-blocking effect of these drugs. The relaxants used at that time included tubocurarine, decamethonium, succinylcholine, gallamine, and di-methyl tubocurarine. Anesthesiology departments throughout the world were encouraged to hold local mortality review meetings that subsequently included reviews of morbidity as well.This paper reviews the ethical considerations, the barriers to reporting and several successful local and international incident reporting systems.

Guffey, Patrick J.; Culwick, Martin; Merry, Alan F.

Pre-filled emergency drugs: The introduction of pre-filled metaraminol and ephedrine syringes into the main operating theatres of a major metropolitan centre

The safe administration of drugs to patients lies at the core of anaesthetic practice. Anaesthesia is unique as a medical specialty where a single doctor routinely prescribes, dispenses, prepares then administers multiple medications, often within an urgent or emergent time scale. Compound this with the fact that many of the medications used are potentially life threatening if given erroneously, it becomes clear that medication safety is fundamental to modern anaesthesia. The introduction of pre-filled metaraminol and pre-filled ephedrine syringes in the RBWH main operating theatres has been highly successful. It has resulted in a decreased overall cost of these drugs to the department, with further improvements in the cost saving margins expected. Published in Australasian Anaesthesia (The Blue Book) 2013.

Nathan Goodrick, Torben Wentrup, Geoffrey Messer, Patricia Gleeson, Martin Culwick and Genevieve Goulding.